Chaos in the Equilibrium: A Rare Complication of Dialysis.

Dialysis disequilibrium syndrome (DDS) is a rare but potentially life-threatening neurologic complication associated with hemodialysis (HD), particularly during initial treatments in patients with severe uremia. It is thought to result from rapid osmotic shifts between the plasma and the central nervous system during dialysis. We present the case of a 36-year-old woman with stage V chronic kidney disease secondary to diffuse lupus nephritis who developed suspected DDS during her first HD session. She presented with acute-on-chronic renal failure, severe metabolic acidosis, a creatinine of 12.09 mg/dL, and a blood urea nitrogen (BUN) of 162 mg/dL. Within 30 minutes of HD initiation, the patient developed headache and nausea, followed by generalized shaking, lateral tongue biting, and postictal confusion approximately 15 minutes after treatment completion, concerning for a generalized tonic-clonic seizure. Neuroimaging and electroencephalography were unremarkable, and she returned rapidly to baseline mental status. HD was subsequently resumed with reduced blood flow and dialysate rates, which she tolerated without recurrence of symptoms, supporting the diagnosis of DDS. This case highlights the importance of recognizing DDS as a clinical diagnosis of exclusion in high-risk patients initiating dialysis. Prevention through gradual urea clearance and individualized dialysis prescriptions remains the cornerstone of management, particularly in patients with severe uremia and metabolic derangements.